Reflection by Kesavan Rajasekharan Nayar
India is one of the few countries where Tuberculosis is still widely prevalent. One of the oldest of human diseases in recorded history is still inhumanly ravaging lives despite India developing one of the most human-centred National Tuberculosis Programs way back in the sixties.1 It gave primacy to the people and focused on the needs of the patients. The program underwent many changes with technology riding over humanism. It does not appear that complete elimination is possible even with such an approach and with a final push that some of the international agencies are attempting. The conditions are still unfavourable in many states in India, where the socio-economic conditions are appalling. And we have the evidence of tuberculosis and other infectious diseases declining in Europe even before sanitary facilities and medical measures were in place. The improvements in health status and the rise in population were attributed to improvements in socio-economic conditions, including food production, as classic studies by Thomas McKeown and others have suggested. This is the main constraint in Tuberculosis elimination as far as India is concerned.
It is claimed that Kerala will be the only state in India which might eliminate the disease by 2020. Kerala’s TB incidence rate is just 67 per 100,000 members of the population as against the all-India rate of 138 per 100,000 members of the population. These case findings have detected only 352 new cases in 2018 in a population of 38 million, which indicates that the end of TB is in sight. It is possible that an active case finding strategy may not be the only cause for this achievement. In Kerala, socio-economic improvements in combination with the availability and accessibility of health care could have influenced this sharp decline. The impact of higher private sector participation also needs to be examined, although the reliability of statistics regarding public and private sector participation in Tuberculosis control is a contentious issue. Some statistics available from a prominent exclusive website devoted to TB reveal that the number of TB patients noted by the private sector (26,324) in Kerala is more than the number reported by the Public sector (20,969).2 On the other hand, according to a 2018 India TB report, 14,522 TB cases are reported from the public sector and 8,232 from the private sector in 2017.3 Notwithstanding such a mismatch in data reports, this is indeed important information that proves useful for developing future TB elimination strategies in other states in India where the public sector case detection rate is higher.. In some states, the difference between the two sectors is huge. It is possible that a number of patients, for socio-economic reasons, might be seeking care from private practitioners which go unreported or unrecorded although exact figures regarding under reporting of TB cases in the private sector is not available.
Even in Kerala, there are constraints galore, especially in behavioural trends among the population such as indiscriminate spitting and coughing, which stand apart from socio-economic factors. Field work conducted by MPH students of the Global Institute of Public Health found that stigmatization of TB patients is also a problem at the micro-level, especially in small communities. Tuberculosis patients and former patients are reluctant to talk about their experiences, most probably due to the stigmatization they experienced after contracting the disease. Health workers find it difficult to ensure compliance to treatment due to this problem. Many treatment strategies like DOTS—Directly Observed Treatment Short course, the internationally recommended strategy for TB control which needs to directly observe and ensure compliance to the treatment, add to the problem when anonymity and confidentiality is low.
The indiscriminate use of anti-tuberculosis drugs outside the TB programme and the rise in Multi Drug Resistant-TB is a major concern in many Indian states; it is also a significant factor slowing down complete TB elimination.4,5 India has the highest burden of MDR-TB which is resistance to first-line anti-TB drugs such as isoniazid, Rifampicin, Pyrazinamide etc. India has reported an alarming increase in the number of MDR-TB which is the highest in the world. The problem of MDR-TB is more in Western India especially in the urban areas of Mumbai, Pune and cities of Gujarat but in Kerala, the rate of MDR-TB is less than other states.
Another issue is the indication of the presence of TB among diabetic patients as WHO says that 15 percent of TB cases globally may be linked to diabetes due to weak immune systems. In Kerala, diabetes is widely prevalent, which therefore necessitates special care to minimize the risk of TB as WHO advises. HIV-TB co-morbidity is also an important issue which needs to be tackled for complete elimination. The presence of migrant workers in large numbers from some North Indian states is identified as a problem for complete elimination, although most of these workers are from younger age groups and are unlikely targets for the bacteria.
Evidently, a technological solution may not be successful given the close link between socio-economic conditions and TB. A humanistic approach to TB elimination should be able to generate multi-sectoral actions involving several ministries of the government apart from the private sector. They include patient support groups, nutrition programmes, hospital based infection control programs, livelihood programs, stigma reduction and an enhanced private sector participation. The possibility of complete elimination in India is perhaps a distant mirage. A final mop-up operation, even to declare the state of Kerala as TB free, requires such a multi-sectoral strategy in combination with focused and targeted actions regarding the issues discussed here.
Kesavan Rajasekharan Nayar is a member of the Global Institute of Public Health and the Santhigiri Research Foundation, Trivandrum, Kerala, India.
[1] Banerji D and Andersen S. A sociological study of awareness of symptoms among persons with pulmonary tuberculosis. Bull World Health Organ. 1963;29: 665-83.
[2] https://www.tbfacts.org/tb-statistics-india/ accessed 25.02.2019
[3] Director General of Health Services, Central TB Division. India TB Report 2018. New Delhi: Central TB Division, 2018.
[4] Chatterjee S, H Poonawala and Y Jain. Drug-resistant tuberculosis: is India ready for the challenge?. BMJ Global Health 2018; 3(4): e000971
[5] Prabhu BP, A Kunoor, A Dutt et al. Anti-tuberculosis treatment stewardship in a private tertiary care hospital in South India. Public Health Action 2018; 8(3): 151